Wednesday, September 10, 2014

TOPEKA — Wichita physician Josh Umbehr has never understood the traditional model of health care reimbursement — the one in which doctors and hospitals fill out pages of forms to bill a patient's insurance company for everything from a $3 test to a $30,000 surgery.

“You don’t have car insurance for gasoline," Umbehr said in a recent phone interview. "Why would you have health insurance for family practice?”

With that philosophy in mind, Umbehr has operated on a kind of service plan for the human body since he opened his practice in 2010.

He sees hundreds of patients at his Wichita clinic, AtlasMD, but he bills no insurance companies. Instead, he charges a monthly membership fee of $10 for kids and $50 for adults for unlimited visits, texts, phone calls, discounted prescription medications and a slew of in-office services like stitching wounds and removing lesions.

“Any procedure we can do in the office is included free of charge,” Umbehr said.

It's what used to be called "concierge medicine," and it used to be mostly for wealthy people. But Umbehr and others in the small but growing monthly-fee model prefer to call it "direct primary care" because they say they're offering it at prices now accessible to the masses.

Umbehr, whose practice now includes two partners and a patient list of more than 1,600, is one of the more high-profile direct primary care physicians in the country. AtlasMD has been written up in the Wichita Business Journal and Bloomberg Businessweek, and Umbehr, 33, spends a chunk of his time these days helping other doctors disillusioned with the traditional insurance model start their own direct primary care practices.

“We had doctors out today, we have doctors out Tuesday, we have a medical student with us," Umbehr said just before the Labor Day weekend. "The momentum for this is picking up. When I started four years ago, they said this would never work or they doubted it. Now I’ll be traveling three of the next four weeks lecturing on this.”

Umbehr also is running for lieutenant governor as a Libertarian with his father, Alma attorney Keen Umbehr, at the top of the ticket.

Josh Umbehr said he's "still doing the math" on whether the state should move its 400,000 Medicaid recipients to a direct primary care plan if he and his dad are elected, so it's not part of the official platform yet. But he's not shy about spreading the gospel of direct primary care on the stump, now that his father has "talked me into running."

"We’re very passionate about this model. We want Kansans to have access to good-quality, affordable health care," Umbehr said. “The race as a whole has several platforms and goals. My key is to advance the cause of direct primary care.”

Gambling on staying healthy

Umbehr faces skepticism from consumer advocacy groups at the state and national level.

“Our concerns around concierge medicine are mostly that we worry that people that go that route are not going to have the best access to a comprehensive range of services,” said Claire McAndrew, private insurance program director for the group Families USA. “That provider can provide you primary care, but are you going to have affordable access to specialty services when you need them?"

A comprehensive insurance policy would cover the primary care as well as specialty services like cancer care and surgeries, minus deductibles and co-pays.

Umbehr and his counterparts say their monthly memberships are not a substitute for health insurance, but serve as a supplement that can reduce a patient's cost in most circumstances.

“We recommend the same thing we have, which is a high-deductible plan,” Umbehr said.

Umbehr said coupling his direct primary care membership with "catastrophic care" health insurance, like his $5,000 deductible plan, can save consumers because such plans generally have much lower premiums than traditional comprehensive health insurance plans with deductibles in the $500-$1,000 range.

McAndrew wonders whether those flocking to concierge medicine are pricing out the possible outcomes, even with catastrophic coverage.

One hospital visit, she said, and a patient could end up having to pay that entire $5,000 deductible out of pocket. Even for young, healthy people, that's a financial risk, she said.

“People are young and healthy until they’re young and fall ill, or they’re young and get into an accident,” McAndrew said. “I think that's a pretty big gamble for young people to take.”

Ryan Neuhofel, who runs a direct primary care practice in Lawrence, said he makes sure his patients understand the risks, but he still thinks most come out ahead if they opt for his monthly fee plus a catastrophic plan.

In a given year most people are unlikely to run into a medical problem that would suck up their entire deductible, like a compound fracture requiring surgery, he said.

“Those type of events are pretty rare; they don’t happen very often to people,” Neuhofel said. “You’re going to need insurance for that. If they have to pay $5,000 because of the deductible, that’s going to stink at the time and they’re going to have to pay for that over time. But is that better than paying $200 a month in premiums for the rest of their life?”

Neuhofel said he carries a $10,000 deductible plan.

A quick glance at the AtlasMD Facebook page reveals comments from satisfied customers like Jason Garraway, a 38-year-old health insurance agent from Kechi.

Because Garraway is self-employed, he had to buy insurance for himself, his wife and their five kids on the private market. Two years ago he meshed his catastrophic coverage plan with membership in Umbehr's clinic.

Garraway appreciates the convenience of being able to contact his doctor any time, via email or phone, and feels like he's getting more personal attention than he did from doctors operating under traditional insurance.

"I am now a client to be served, rather than someone who grabs a number in a line to see my doctor when it is my turn for 10 hurried minutes after waiting for an hour in a waiting room," Garraway said.

Garraway recently was dealing with a persistent cough. By Sunday evening it had gotten bad enough that he decided to send an email describing his symptoms to his AtlasMD doctor, Doug Nunamaker, who called in a prescription to a nearby pharmacy.

"I had treatment and medicine in my hands within two hours of when I emailed Doug at 6 p.m. on a Sunday," Garraway said.

That ease of use has made his family more proactive when it comes to seeking preventive care, Garraway said.

ACA considerations

Like Umbehr, Neuhofel said his practice has grown faster than he expected since he started it three years ago. He has more than 600 patients and will likely cap his practice at 700 soon.

“I’ve seen a big shift in the last year," Neuhofel said. "More and more people are approaching us, as opposed to us approaching them and trying to sell them on the idea.”

Neuhofel has a fee structure similar to Umbehr's, and most of his patients are below the median income level, he said.

He makes each new patient sign a form stating that they understand his recommendation to pair his plan with some type of insurance, but he estimated that about 70 percent are uninsured and coming to him because they can't afford a comprehensive insurance plan.

Katrina McGivern, communications director for the Kansas Association for the Medically Underserved, said that could present another problem.

Under the Affordable Care Act, Americans who do not carry health insurance face a penalty that started at $95 a year. A clause in the health reform law states that a concierge plan coupled with catastrophic care insurance qualifies as "wrap-around" coverage, while a concierge plan alone does not.

“Truthfully, by law they should be getting insurance through the (online) marketplace or they’ll face the penalty by tax time,” McGivern said.

The online insurance marketplace created by the ACA offers subsidies to buy insurance based on income. But Kansas' decision not to expand Medicaid has created a gap in that scheme. Thousands of Kansans who would have been eligible for Medicaid under the expansion make too little money to qualify for subsidies on the marketplace.

Even for the uninsured who fall in the coverage gap, though, McGivern said only some would benefit from paying a monthly fee for primary care.

“If you’re frequenting the doctor, that could possibly save you money,” McGivern said.

Sean Gatewood, interim executive director of the Kansas Health Consumer Coalition, said his organization has no official position on direct primary care. But he also said he isn't sure it's the answer for the uninsured or those struggling with health care costs.

“That doesn’t seem workable for the broad population,” Gatewood said.

Neuhofel said the savings are widespread, and come from attentive preventive care.

“They’re getting really good primary care," he said. "I’m managing their diabetes, and a lot of downstream costs are being reduced.”

Effect on physician shortage unknown

Direct primary care practices grew by 25 percent in 2013, according to the American Academy of Family Physicians, which endorses the direct primary care model as consistent with its goals.

"The DPC contract fee structure can enable physicians to spend more time with their patients, both in face-to-face visits, and through telephonic or electronic communications mediums should they choose, since they are not bound by insurance reimbursement restrictions," a statement on the academy's website reads.

Olathe doctor Douglas Brooks said patient care time — as opposed to paperwork time — drew him to direct primary care.

Unlike Umbehr and Neuhofel, who chose the model straight out of medical school at the University of Kansas, Brooks had decades of practice under the traditional insurance model when he decided to switch last year.

“I really had seen just about every aspect of medical management, and it really just kind of came down to the state of medicine today is so out of control that I had to do something," Brooks said. "This was something that had caught my eye back in the mid-2000s, and I finally decided I had to jump on it.”

Brooks already had a large panel of patients he had to break the news to, and did so in two informational seminars.

“Part of the reason for doing (the seminars) was to ask ‘Are you willing to follow me if I do this?'" Brooks said, "And the overwhelming response was 'Yes.'”

Brooks said most of his patients stayed on and he added new ones from inside and outside Johnson County, including many who take advantage of the opportunity to contact him via phone and email with pictures of problems for him to diagnose. Brooks said he has reached his 2,000-patient cap and started a waiting list.

That number sounds like a lot compared to Umbehr and Neuhofel, but Brooks said under the traditional insurance model he and a couple of physician assistants handled patient loads of up to 18,000.

Brooks' practice is perhaps the newest direct primary care office in Kansas. Concierge Medicine Today's website lists Neuhofel, Umbehr and Umbehr's AtlasMD partners Nunamaker and Michael Palomino as the only physicians in the state practicing under the model. In Missouri, it lists only St. Louis-based doctor Gayathri Raman and Ann Riggs of Platte City.

But the list is growing. Neosho County doctor Joseph Sheppard's website bills him as the "Free Market Physician" and says he opened his direct primary care practice in July. Umbehr said he helped another Wichita doctor, Jeffrey Davis, get started this year.

One of the persistent criticisms of direct primary care is that by allowing physicians to see fewer patients, it exacerbates the existing shortage of primary care doctors.

Umbehr said that's not the case, arguing that the model will attract doctors who otherwise would have become specialists to try primary care and will keep doctors like Brooks from burning out and retiring early.

Brooks said that if he had kept dealing with insurance companies under the old reimbursement model, “I would have been looking toward retiring as soon as I could afford to do so.”

And now?

“I've got a good 20-some years left, probably,” Brooks said.

McAndrew, from Families USA, said there are anecdotes about direct primary care physicians spending more time with each patient but no measurable metrics.

She also said there are other ways to lessen the paperwork burden and streamline reimbursement for doctors.

“We believe there are negative consequences to the health care system when doctors are pulling out of health care networks,” McAndrew said.

For better or worse, Umbehr said that will continue to happen as long as health care costs keep climbing and patients seek alternatives to traditional health insurance.

“Health care is a commodity, like gas or milk," Umbehr said. "Everybody needs it and everybody wants it to be more affordable than it is.”